Date: Thu, 8 Aug 1996 02:56:26 -0300 (ADT)
From: "Kevin R. Speight"
Opening Doors: What Health Professionals
Should Know About Their Gay, Lesbian, and Bisexual Patients
by Kevin R. Speight, Dalhousie University Medical School Class of '97
(kevinsp8@is.dal.ca)
Contents:
Introduction
What does 'homosexual' mean?
What do "gay", "lesbian", and "bisexual" mean?
Who are gays, lesbians, and bisexuals?
Why is an understanding of sexual orientation issues relevant to
providing health care?
What is homophobia?
What forms do homophobia and heterosexism take?
How can you combat homophobia?
When and how do you ask a patient about sexual orientation?2
How can disclosure of sexual orientation best be encouraged?
Confidentiality
Should physicians ever disclose their own sexual orientation to
patients?
What terms are appropriate to use?
What is "gay bashing"?
Spousal Abuse
Suicide, depression and substance abuse
When medical sources are in disagreement over gay and lesbian
issues, which do you believe?
When and to whom should I refer gay and lesbian patients?
Do lesbians need reproductive health care?
Are transsexuals and transvestites homosexuals?
What safer-sex information should I make available to gay and
lesbian patients?
Emerging Issues
Where can I go for more information?
Conclusion
References
Introduction:
While information on biological processes, diagnosis and therapy
remain the core of medical education programs, many medical
educators have recently recognized the importance of ethical,
psychosocial, and sociological concerns to aspiring physicians.
Here I address the question of homosexuality and medicine. I hope
to provide a basic introduction on homosexuality and homosexuals to
readers unfamiliar with the topic, to present a rationale for the
importance of examining gay and lesbian issues in health care, and
to give brief overviews of some selected topics relevant to the
health care of gays and lesbians directed primarily at medical
students.
What does 'homosexual' mean?
A homosexual is a person who exhibits "sexual desire or
behaviour directed toward a person or persons of one's own sex."(1)
The problem with using the word homosexual is that it assumes there
are only two types of diametrically opposed sexual orientations, homo-
and heterosexual, and that people are either one or the other.
Sex researchers believe that people exist on a continuous
spectrum of sexual preference. The Kinsey Scale rates people's
sexual responsiveness on a scale of 0 to 6, with 0's exclusively
heterosexual, 3's equal homosexual and heterosexual, and having sex
exclusively with someone of the opposite sex, and 6's exclusively
homosexual. Most people lie somewhere between the two extremes.(2)
However, this classification can still lead to confusion, due
to the necessity to consider both desire and sexual activity in
classifying people's sexual orientations. It is entirely possible
for someone who is mainly attracted to people of the same sex to
have sex only with the opposite sex throughout his/her life. As
well, sexual orientations may change throughout a person's life.
A person who will later identify with a homosexual orientation may
repress his/her attraction to same-sex people for years, and only
become aware of his/her homosexuality after a period of exclusive
heterosexual contact. People may go through periods of confusion
when they honestly don't know what their sexual orientation is.
Finally, people who have homosexual sex may not identify themselves
as homosexual.
Homosexuality can involve a cultural identity, but not
necessarily. Some people who have homosexual sex label themselves
as 'gay' or 'queer', socialize with other homosexuals, and may
adopt elements of a gay subculture (e.g. characteristic phrases,
manners of dress, literary and cinematic allusions). Others who
have homosexual sex do not identify themselves as homosexual, may
be married to an opposite-sex partner, and may even express anti-
homosexual views. The point at which one labels a person as
homosexual is unclear.
It can be useful at times to use the term "homosexual" or
"bisexual" to describe people who, as a minimum, are sexually
attracted to members of the same sex. It is important to note the
imprecision inherent in this term, and to realize the wide variety
of sexual experience and feelings possible in people.
What do "gay", "lesbian" and "bisexual" mean?
Whereas homosexual is a term coined by doctors in the 19th
century to describe a medical disorder, "gay" is a term that was
first used as a secret code among members of a subculture, and
later as a public self-designation by homosexual-rights groups.(3)
It has a similar meaning as homosexual, but is preferred by many
gay people, perhaps because it sounds less "clinical" and is a word
chosen by gay people instead of being imposed upon them. Many
homosexual women prefer to be called "lesbians". People who wish
to be known as being sexually attracted to members of both sex
often prefer to be called "bisexual". Some homosexuals proudly use
terms like "fag", "dyke" and "queer" to describe themselves--such
usage is not always appreciated by all homosexuals, probably
because they were first used (and are still) as terms of derision
by some people. I will use the terms "gay" to refer to people who
have predominantly same-sex desires, and, when further distinction
is necessary, "gay man", "lesbian" and "bisexual" in this text.
Who are gays, lesbians and bisexuals?
Homosexual behaviour is a trait which cuts across all
cultures, races, occupations, nationalities, intelligence levels,
and abilities.(4) Studies surveying the prevalence of
homosexuality generally put the percentage of gay people at 5-10
percent of the population. (5) Kinsey et al's surveys of sexual
behaviour found nearly 40% of the population of the U.S. is either
homosexual, bisexual, or has experienced some same-sex sexual
contact or feeling at some time in their lives.(3) These
statistics remain estimates due to the reluctance many people feel
in revealing homosexual activity or desire, but based on them, a
physician who sees 30 patients in a day can reasonably expect 1-3
of them to be gay or lesbian. Gays and lesbians may engage in
kissing, petting, mutual masturbation, and oral genital relations
which are essentially similar and analogous to those activities as
practiced by heterosexuals (6). Anal intercourse and stimulation
are more common among gay men than among heterosexual couples, but
a substantial number of homosexual men find this practice
distasteful and engage in it rarely or not at all.(6) Anal
intercourse should not be considered the sole domain of gay men--
some 30% of heterosexuals have tried it and some do it
regularly(7). Most homosexuals do not show clear-cut active or
passive preferences in this sexual relations.(6)
Why is an understanding of sexual orientation issues relevant to
providing health care?
Unfamiliarity with issues surrounding gay and lesbian health
care lead to a decreased quality of health care: "Misconceptions
and unexamined personal attitudes about homosexuality on the part
of physicians can result in grave, even life-threatening,
disservice to homosexual patients.(8) There are several reasons
for this:
Sexual orientation may be a cause, contributor, or risk marker for
health problems
Gay people have different rates of health problems than
heterosexuals. Gay men have higher rates of HIV infection than
heterosexual men, lesbians, or women as of this writing.(9) Gay
men may be at higher risk for certain sexually transmitted diseases
or syndromes (syphilis, anal and pharyngeal gonorrhea, enteric
infections, hepatitis, and certain intestinal complaints), and at
decreased risk for others (chlamydia and trichomoniasis).(10)
Sexually transmitted diseases are likely to have different
presentations in gay men than in other people (oral and pharyngeal
syphilis is more common in gay men than in other people, who are
more likely to present with genital syphilis), and optimal
treatment for sexually transmitted diseases may be different for
gay men then for others.(10) Preferred diagnostic procedures may
differ for people presenting with the same symptoms, depending on
their sexual orientation (patients with rectal pain, diarrhea,
colitis, or large bowel symptoms who are gay need not have an
elaborate workup for ulcerative colitis until enteric infections,
anal gonorrhea, and anorectal trauma have been ruled out.(10)
Lesbians are at higher risk for breast cancer than heterosexual
women.(11)
Gays are also more likely to present with certain psychiatric
problems, such as suicide attempts, and substance abuse.(12) While
gay people may experience these problems due to the same factors as
heterosexual people, negative attitudes towards homosexuality by
themselves or by others can also contribute to them, and thus it
may be impossible to treat the causes of a patient's psychiatric
problems without knowing their sexual orientation.
Gays, or people thought to be gay, may be physically assaulted
for their sexual orientation (called "gay bashing"). Knowing the
sexual orientation of such patients can aid law enforcement
officials in preventing future incidents and in pursuing legal
redress of such injuries.
These observations change with differing temporal, geographical,
social and environmental conditions, and thus may not always be
valid, but they demonstrate the value of knowing a patient's sexual
orientation in diagnosing and treating disease.
A reluctance to discuss sexual orientation issues may preclude
discussion of health issues
If a gay patient doesn't feel comfortable revealing his or her
sexual orientation, this makes it unlikely that medical problems
related to sexual orientation will be dealt with. For example, if
a gay patient with a sexual dysfunction isn't able to communicate
his sexual orientation, many standard questions the practitioner
should ask cannot be answered fully. Answering questions about a
patient's relationship with his partner, under what circumstances
has the patient ever had an orgasm, type of sexual fantasies the
patient has, or sexual positions which change sexual response(13)
often require the patient to reveal sexual orientation--if this is
precluded, proper information cannot be obtained and the patient
cannot be successfully treated. Other problems which fall into
this category include spousal abuse, giving safer sex instructions,
psychiatric problems related to sexual relationships or homosexual
status, and enquiring about a patient's social supports when
considering treatment options.
Invisibility or negative attitudes worsen the doctor-patient
relationship
The therapeutic relationship between a physician and a patient
is an important tool of medicine; along with other "placebo"
effects, it may represent the difference between success and
failure of therapy.(14) Therapeutic relationships share certain
important factors, and a physician's attitudes toward homosexuality
could influence these factors. The patient brings to therapy an
expectation that help is possible(15). If, for example, a patient
wishes a happier sexual relationship with his partner, and the
physician feels no one can be happy in a homosexual relationship,
then the expectation of help is destroyed. Therapy offers a safe
place for taking risks(15). Negative attitudes about homosexuality
make a patient less likely to take risks of disclosure and
experimentation with new behaviours. When a patient realizes a
physician is assuming he is heterosexual, or when a physician
expresses negative attitudes toward homosexuality, some gay
patients are less likely to trust and respect the physician.
Without this trust and respect, an inferior therapeutic
relationship may occur.
A failure to disclose sexual orientation may be due to the
physician assuming a patient is heterosexual (and the patient thus
not having a chance to indicate otherwise), or to the patient's
fear of disclosure. A physician need not be consciously aware of
displaying overt disapproval for the patient to receive negative
messages. Studies have shown that attitudes translate into
behaviour. Experimental subjects tend to evaluate homosexuals more
negatively than heterosexuals, all else being equal; they tend to
maintain a greater personal distance from homosexuals, such as
sitting further away and avoiding working with homosexuals.(5)
Thus, negative attitudes, even in the absence of a desire to treat
homosexuals differently, can be conveyed subtly to patients, thus
impairing professional objectivity.(5)
What is homophobia?
This was a term coined by a psychiatrist, George Weinberg, in
1972 to mean the dread of being in close quarters with homosexuals.
He argued that it commonly occurs in men who belittle homosexuals
to bolster their own self-importance, and that in doing so, they
heighten their fear of human variety and make it impossible to have
homosexual friends, thus losing the possible benefit of a wider
viewpoint.(16) Of late it is used to describe "any negative
personal attitudes or behaviours about homosexuality"(17) One's
attitude about homosexuality is not simply a matter or approval or
disapproval. Negative attitudes can range from repulsion to pity
to tolerance (homosexuals haven't "grown up" yet, and are to be
treated with the protectiveness as indulgence of a child) to
acceptance (implying that there is something negative to
accept).(17) Positive attitudes can range from support to
admiration to appreciation to nurturance(17). These positive
levels of attitudes involve being aware of the climate homosexuals
live in and the discrimination they face, assuming that lesbian and
gay people are indispensable to society, and working to safeguard
gay and lesbian rights.
A term less frequently used when speaking about attitudes
towards homosexuals is heterosexism; this may be defined as "the
continual promotion by institutions of the superiority of
heterosexuality and the simultaneous subordination of
homosexuality...[and] the assumption that everyone is heterosexual
unless known otherwise."(17) While others might debate what one's
attitudes towards homosexuality should be, it is here sufficient to
point out that negative attitudes towards homosexuals tend to
worsen the health care they receive.
What forms do homophobia and heterosexism take?
The most blatant form homophobia takes is overt negative
statements or actions. A gay patient may be devastated by hearing
a respected figure tell him "All your problems stem from your
homosexuality" or "That's the sort of problem you should expect is
you are going to be gay", or "With my help, you can overcome your
homosexuality". A refusal to acknowledge the importance of letting
a homosexual's partner visit or participate in health-care
decisions could cause distress. An inappropriate sneer or laugh
can undermine the patient-doctor relationship.
Homophobia may take the form of holding or expressing
misinformation, myths, or stereotypes about homosexuals. Asking a
gay man who has attempted suicide how long he has "wanted to be a
woman" is an example of one stereotype about gay men--that they
feel like women trapped in men's bodies. Expressing surprise upon
learning that a person is gay because they look "so straight"
expresses the stereotype that certain "types" are gay. This
preconceived "type" for the gay man may look effeminate, strangely
dressed and physically weak, and may have characteristics like
being creative or artistic, being emotionally unstable and unhappy,
having a dominating mother. The lesbian is sometimes thought to be
mannish, physically active, unattractive, and anti-male. Other
preconceived notions about gay people is that they are mostly
promiscuous, that they are exclusively gay, and that they all
engage in or are interested in certain sexual practices such as
anal intercourse, sado-masochism, or pedophilia. These stereotypes
are clearly not true of all gays: "there is as wide a personality
variation among homosexuals as among heterosexuals...the seeking
out of children as sexual objects is much less common among
homosexuals than among heterosexuals".(6) Holding these
stereotypes is as unfair as assuming certain races are less honest
or intelligent, or that women do not have the temperament for
medicine.
Homosexuals are often "invisible" in our society--they are not
talked about, and they are presumed to be "other people"--not one's
friends, relatives, or patients. Some homosexuals, for fear of
discrimination or dislike of their sexual orientation seek this
invisibility. However, a lack of visibility in medical education
can lead to inappropriate health care. Gay men do not only present
with HIV-related problems--they can also have all the medical
problems that heterosexual men do. Having hypothetical cases which
never include gay men is not an accurate reflection of society.
Similarly, not all pregnant women are heterosexual. Including
examples of homosexual patients in medical problem-solving cases
would reflect the reality of the patient population. A result of
the invisibility of homosexuality is the assumption that a patient
is heterosexual, unless specifically told otherwise. A negative
response to the question "do you have a girlfriend" by an unmarried
male should not result in the assumption that he is unattached.
Indeed, a more open question might be "are you currently in a
relationship", or a similar non-gender specific inquiry. It may be
difficult to remember not to make assumptions about sexual
orientation; however, by doing so, some gay patients will feel that
their way of life is acknowledged by their doctor, and will feel
more comfortable and confident in their doctor.
Even if a doctor is not oblivious to the existence of
homosexuality among her or his patients, discomfort talking about
homosexuality and avoidance of discussing it can lead to the same
result. A lack of knowledge about homosexuality and its relation
to health provision can also lead to suboptimal medical care, even
when a physician is aware of the possibility that a patient could
be gay, and is comfortable discussing the topic.
A negative attitude about homosexuality can lead to the
presumption that a gay patient's health problem is caused by his
homosexuality. A common example is psychiatric complaints. While
it is true that a gay patient's depression may be related to the
fact that he is gay, it may also be because he has stressors at
work, at home or socially, or it may have an organic cause.
Suicide, substance abuse or pneumonia in the homosexual may not be
at all related to homosexuality, and a wise diagnostician seeks
more information before reaching conclusions.
How can you combat homophobia?
Studies show that people who know at least one other gay person
are less likely to feel discrimination against homosexuals is
appropriate.(18) Thus educating oneself about homosexuals is a
good place to start combatting homophobia on a personal level.
Magazines, literature, journals and computer groups devoted to gay
themes are excellent resources. If you already know gay people,
talk to them about their experiences and lives. If you don't know
any, you could attend a meeting of a gay group in your area. Being
conscious of any assumptions you are making or any discomfort you
feel surrounding homosexuality, and examining the reasons you have
these feelings can be helpful. If you are yourself gay, coming out
is a good way to reduce the invisibility of gay people and to help
dispel negative stereotypes. If you find unusual difficulty
dealing with gay issues or gay patients, you could seek counselling
to investigate your feelings, or as a final resort, avoid treating
gay patients: "When personal emotional attitudes interfere with an
optimal physician-patient relationship and patient care, the
ethical course is to explain one's dilemma openly and refer the
patient."(6)
On a community level, you can leave gay-positive posters and
pamphlets around your office, and challenge homophobic comments,
jokes, or attitudes made by colleagues or patients. On a
population level, you can support laws and public education
programs designed to combat discrimination against homosexuals.
When and how do you ask a patient about sexual orientation?
There are divergent views on issues like this. Some argue that
a person's regular family physician should ask about sexual
orientation: "These questions are neither academic nor prurient.
Failure to know a patient's orientation dulls a physician's
alertness to atypical manifestations or loci of some illnesses or
lesions"(8). Others contend that such inquiries should only be
made in the event the patient presents with symptoms which could be
directly sex-related (e.g. STDs, sexual dysfunction). When
considering this question, one must be sure that personal
discomfort with the issue of homosexuality doesn't inappropriately
limit patient questioning, and that ignorance of all the potential
medical issues related to homosexuality hasn't improperly made the
question seem irrelevant.
How can disclosure of sexual orientation best be achieved?
When dealing with sexual matters in general, begin with a sexual
history only if the patient's chief complaint is of a sexual
nature; otherwise, wait until you have established a rapport with
the patient in the interview.(15) It can be helpful to indicate in
your questions that many people have had homosexual feelings, in
order to allay patient concern that their sexuality is abnormal:
"Many people have sexual experiences with members of the same sex
at some point in their lives. Have you had any experiences with
other women (men)?"(15) When talking about relationships or sexual
experiences, use neutral terms like "lover" or "partner" to avoid
making it difficult for a patient to tell you about homosexual
experiences. Both defense and denial about sexual orientation may
occur by the patient under the best of circumstances, but they are
greatly minimized by a matter-of-fact, nonjudgemental manner.(8)
Discomfort or embarrassment in talking about sexual orientation
will be communicated to your patient(15) and will hamper
disclosure.
If you doubt the answer a patient gives to a question about
sexual orientation, and you feel it is medically important to know,
it may help to explain to the patient why it is important for the
physician to know, and that the information is confidential--direct
confrontation may be counterproductive.
Confidentiality:
A patient's sexual orientation is part of his/her medical
history, and should therefore be kept confidential where possible.
The question of whether sexual orientation should be recorded on a
patient's medical records is more difficult--on one hand, such an
annotation can aid scientists conducting research on sexual
orientation issues (the lack of such annotation was given as the
reason why a recent study on "gay brains" excluded lesbians(19)).
On the other hand, thought must be given to whether employers or
insurance companies may see such an annotation and whether the
patient will face adverse consequences because of this. One
suggestion is to make annotations concerning sexual orientation
with coded symbols particular to the physician.
Should physicians ever disclose their own sexual orientation to
patients?
One author claims that
heterosexual therapists, even those who wear wedding
bands, usually quote therapeutic neutrality, claiming
that sexual orientation should never be disclosed. In
contrast, the response from gay identified clinicians
seems to be overwhelmingly in favor of personal
disclosure of their sexual orientation to gay patients,
but not necessarily of any further specific information.
More importantly, many gay therapists believe that the
disclosure is an essential and therapeutic part of the
process, and example of role modelling.(20)
Another is more emphatic: "minority therapists...must come out
and reveal themselves because they must model being genuine".(20)
A gay man may find a heterosexual male physician intimidating, and
prefer to deal with a female.(20) However, a heterosexual
therapist who reveals his or her sexual preference may allow for an
honest projection of fears, assumptions, and negative
transference.(20) These issues are more important in
psychotherapy, but the impact of physician disclosure should be
considered in all medical settings.
What terms are appropriate to use?
When in doubt, use the most neutral and widely accepted terms
for sexual orientation and sexual activity, but use the patient's
own vernacular when it is known.(15)
What is "gay bashing"?
As an adjunct to other forms of discrimination gays and lesbians
face, they may be physically assaulted based on their actual or
presumed sexual orientation. Statistics on such "hate crimes" are
only beginning to be kept, and do not fully reflect the extent of
the problem, because many gays and lesbians do not report the
crimes. Patients who have been assaulted may also not disclose the
nature of the assault to the physician. Patients may require
counselling after such an attack, and may also obtain emotional
benefit from legal remedies. For these reasons, physicians should
be alert to the possibility of gay-bashing in assault cases, make
disclosure comfortable by the patient, and refer him/her to
appropriate resources. Prevention can be encouraged by advising
patients to take personal security measures such as self-defense
courses, not travelling alone, and avoiding confrontations.
Spousal Abuse:
Victims of spousal abuse are commonly thought to be women abused
by male partners. Physicians should be aware that abuse (physical,
emotional, and sexual) can also occur in lesbian and gay
relationships. One gay man told of how the ignorance of health
care providers adversely affected his situation: "[My abuser] once
agreed to counselling. The psychiatrist having no background in
gay male abuse doesn't see the problem. The abuser refuses to ever
go again....I tried to commit suicide twice....No one asked why I
tried to kill myself."(21)
Suicide, Depression, and Substance Abuse
Studies have shown that gay men and lesbians are a significantly
higher risk for suicide and alcoholism(12). Discrimination faced
by lesbians and gays is a major factor explaining these statistics-
-nothing inherent in homosexual activity makes a person self-
destructive.(12) Lesbian and gay youth seem to be at particular
risk--one study should gay youth are two to three times more likely
to attempt suicide than heterosexual youth, and up to 30% of those
teenagers who do commit suicide are gay or lesbian(22) However,
this relationship is not always recognized by physicians. Thus in
patients presenting with depression, suicide, or substance abuse
issues, it is important to determine the role sexual orientation
may be playing. It is also important to note that gays and
lesbians may also experience these problems for reasons unconnected
to their sexual orientation--a lesbian patient may be depressed
because of poverty, or may drink because of an inability to cope
with a stressful job, for example.
When medical sources are in disagreement over gay and lesbian
issues, which do you believe?
The general medical view of homosexuality has changed over the
years--from advocating castration of male homosexuals, less than 60
years ago(3), to asserting that homosexuality is not a disorder
today. For that reason, the currentness of a medical book or
article is relevant when using it for medical information on
homosexuality. Some aspects of psychiatry are necessarily based on
theories (e.g. Freud's psychosexual theory of development) and are
not amenable to rigorous scientific testing. For this reason, the
assumptions and biases of a writer using this technique to produce
information on gays and lesbians must be questioned. The author's
sexual orientation and cultural surroundings could be important to
how she perceives normal and abnormal human behaviour.
Studies which attempt to study homosexuals in a scientific
manner face an important problem which can affect their validity:
it is difficult to obtain a truly representative sample of
homosexuals, due to the limitations in definitions of homosexuality
and the reluctance of some gays and lesbians to self-identify as
homosexual to a researcher. If a study is done outside an
establishment where gay men are known to congregate for sexual
encounters (i.e. a bathhouse), for example, data on the average
number of sexual partners for gay men are only representative of
those men who frequent such establishments, not of gay men in
general. Data on the mental state of lesbians obtained from
lesbians being treated in a psychiatric hospital are not
representative of all lesbians. Thus it is necessary to critically
evaluate medical literature on gays and lesbians for such factors
as the date of the study, the biases of the author, and the
representativeness of the sample.
When and to whom should I refer gay and lesbian patients?
The normal customs regarding referrals apply to gays and
lesbians (i.e. when you lack the time or expertise to deal with a
patient, refer to a professional who can better manage the
problem). It may be valuable to avoid referring a gay or lesbian
patient to a professional who you know to have strong negative
views of homosexuals, when possible, in order to provide for the
best possible doctor-patient relationship. Especially with a
patient who has medical issues relating to their sexual
orientation, you may wish to consider referring to a self-
identified gay professional: "Given the paucity of training on
issues of a gay affirmative psychotherapeutic approach, the burden
is on the non-gay therapist to be competent...most gay therapists
who intentionally work with gay couples have a decided
advantage"(20)
Do lesbians need reproductive health care?
Since lesbians do not generally have male partners, many people
aren't aware that some choose to have children, and many other
people disapprove of such action. Nineteen out of 33 fertility
clinics surveyed recently in Canada said they would refuse
treatment to lesbians(23) When making a decision to refuse
treatment, the following issues could be rewardingly considered:
Is there a good medical reason to deny such service? Does such
denial have anything to do with my assumptions that homosexuals are
child molesters, or that sexual orientation in a child is
determined by the sexual orientation of the parents, or that
homosexuals are incapable of making good parents? If so, have I
investigated these assumptions thoroughly? Is such a refusal
consistent with the letter and spirit of the Canadian Medical
Association Code of Ethics, the Canadian Charter of Rights and
Freedoms, and any human rights legislation in my province?
Are transsexuals and transvestites homosexual?
The majority of transvestites (those who wear clothes of the
other gender) and transsexuals (those who feel a dissonance between
their gender assigned at birth and the gender role they wish to
assume) are heterosexual.(15) Their situation has in common with
homosexuality the fact that they are challenges to traditional
gender roles, and that many transgendered people are homosexual.
As well, activists who label themselves "queer" have undertaken to
include transgendered rights issues with those of homosexual
rights. As with definitions of homosexuality, there are problems
with definitions of these transgendered people. While transvestism
is for some a paraphilia, others dress as the opposite sex for
broader social reasons. Transvestism and transsexualism may
overlap. The current medical definition of transgendered people as
deviants and disordered(15) people could be amenable to similar
criticisms used against the medical definition of homosexuality as
disease, which existed until recently. For example, when treating
transgendered people who are depressed or suicidal, it may be
useful to examine whether these feelings are an inherent part of
the "disorder" of transvestism or transsexualism, or whether they
are merely a result of the discrimination and disapproval faced by
these patients. Efforts to change these traits must be balanced
with the testimony of transgendered people who report greater
happiness and satisfaction after they embraced their desired gender
roles(24).
What safer-sex information should I make available to gay/lesbian
patients?
Safer-sex pamphlets are commonplace in physicians' offices now,
but few seem to be directed specifically to gay patients. You may
wish to consider obtaining pamphlets which are gay-specific, gay
positive, and even erotic. Safer-sex information put out by gay
organizations tends to be more specific, more appealing to its
audience, and, as one study showed, more effective than other
safer-sex information.(25) Gay men are more likely to be receptive
to safer-sex information which communicates to them in a way that
is erotic and non-judgemental.(26)
Emerging Issues:
The rapid rise of genetic technologies may give rise to new
ethical issues in the future. For example, if a genetic cause for
sexual orientation were identified, would it be acceptable for
women to use this test to abort fetuses based solely on the
probable sexual orientation of the unborn child? If a way were
found to change sexual orientations, or to influence the future
sexual orientation of a child, should these technologies be used?
These issues may test the tolerance, compassion, and ethical
standards of the medical profession.
Where can I go for more information?
Via computer on the Internet, considerable information can be
gleaned from newsgroups such as soc.motss, soc.bi, sci.med.aids,
alt.politics.homosexual, alt.sex.motss, alt.sex.homosexual,
alt.transgendered, and others. The electronic mailing list glb-
medical is currently run and moderated by the author, and can be
reached at kevinsp8@ac.dal.ca.
Local gay and lesbian organizations can provide information and
referrals. For example,
GALA NS (Gay and Lesbian Association of Nova Scotia) 2112
Gottingen St., Halifax, B3K 3B3, 423-2292.
Gay Alcoholics Anonymous 461-1119
Lesbian, Gay and Bisexual Youth Groups, Planned Parenthood N.S.,
6156 Quinpool Rd., Halifax, 492-0444 (Maura)
BGLAD (Bisexual, Gay and Lesbian Association at Dalhousie) 494-
1415, third floor of the Dalhousie Student Union Building.
PFLAG (Parents, Families & Friends of Lesbians and Gays) Ron at
443-3747.
Safe Harbour Metropolitan Community Church 443-7751
AIDS-Nova Scotia 425-4882. Inform-AIDS toll-free hotline: 425-2437
Gay/Lesbian/Bisexual Line 423-7129
Nova Scotia Persons With AIDS Coalition 429-7922
Many other gay organizations exist in Nova Scotia and in other
provinces. The Gaezette can be consulted for more information (Box
34090, Scotia Square, Halifax, B3J 3S1). It is available free at
several places in Halifax and elsewhere, and is a resource you
could consider placing in your office.
Some counsellors advertise to the gay community, for example,
Dr. Blye Frank, 425-4534, Jenna Smith, 422-0087, ext. 61, and
Darlene M. Young, 461-9443. Other professionals knowledgable with
gay and lesbian health care can be found by asking colleagues or
consulting local gay organizations.
The Gay and Lesbian Medical Association is composed mainly of
gay and lesbian physicians and is concerned with gay and lesbian
health care issues. They can be reached at 211 Church St. Suite
C., San Francisco, CA 94114, ph 415-255-4547, e-mail
gaylesmed@aol.com. They are currently expanding into Canada. The
American medical student's group has a gay/lesbian caucus which are
also active in these issues.
Conclusion:
It is important to emphasize that this essay is only a brief
overview of some of the issues important in providing health care
to gays and lesbians. Further investigation of these topics is
encouraged, and have hopefully been facilitated by their inclusion
here. Attitudes and information on gays and lesbians are
constantly changing, and thus physicians must keep up-to-date on
these issues.
It is important that heterosexual physicians join many gay and
lesbians physicians in an increased awareness and understanding of
these issues and work for positive change. A substantial increase
in the quality of health care is possible as a result of such
awareness and understanding.
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